1. Improving Quality of Care: Role of Rapid Response Team and Quick Assessment Unit Department of Pediatrics and Department of Anesthesiology and Critical Care, Driscoll Children’s Hospital, Corpus Christi, TX May 2010Corpus Christi Pediatric Society May 2009Corpus Christi Pediatric Society May 2009 Corpus Christi Pediatric Society May 2009 Ranjana Sarma, MD Madaiah K. Talakadu, MD Keshava M N Gowda, MD Ramon J Rivera, MD, FAAP Alexandre T. Rotta, MD, FCCM, FAAP

2. Abstract The number of in-hospital pediatric cardiopulmonary arrests that occur outside of the intensive care unit and carry a very poor prognosis, has significantly decreased with the institution of a Rapid Response Team (RRT) We continue to analyze the role of the RRT and also hypothesize that the implementation of a Quick Assessment (QA) unit would optimize resource allocation and triage by identifying the sicker subset of patients, intervening early and hence reduce the number of hyperacute rapid response calls (occurring within 4 hours of hospitalization)

3. RESULTS: Among the patients admitted from the pediatrician’s office, the number of rapid response calls dropped from 17 (in 2008) to just 1 (in 2009 after QA) and there were no hyperacute rapid response calls from the same patient population since the institution of the Quick Assessment unit. The time to a rapid response call also increased from 67.6 hours in 2008 to 87.2 hours again symbolizing the success of the QA unit in buying more time to actively intervene and stabilize patients.

4. Restrospective analysis of the number of cardiorespiratory arrests 3 years before and 2 years after the implementation of the rapid response team showed that RRT was associated with a significant decrease in the occurrence of cardiorespiratory arrest outside the PICU (0.68/1000 admissions in 2009 vs 0.73/1000 admissions in 2008 vs 0.81/1000 admissions from 2005-2007) and improved survival to hospital discharge after a code blue event from 46% (2005-2007) to 75% (2008) and an ideal 100% (2009) We concluded that the rapid response team continues to improve patient survival and that Quick Assessment has effectively decreased the number of hyper acute RRs among direct admissions and also improved quality of patient care

5. Background According to the Institute of Medicine, 44000 to 98000 preventable deaths occur annually in the US One of the strategies recommended by Institute for Healthcare Improvement ( IHI -100,000 Lives campaign) was the implementation of a Rapid Response Team (RRT) in every hospital

6. Background In-hospital pediatric cardiopulmonary arrests that occur outside of the intensive care unit account for between 8.5% and 14% of the total number of in- hospital arrests Arrests outside of the PICU carry a very poor prognosis with mortality rates of 50 to 67% Reduction or elimination of such arrests should be a high priority

7. Background The Pediatric Early Warning Score (PEWS) is a clinical tool designed to assess the likelihood of future clinical deterioration in children Since 2008, an adapted version of PEWS has been obtained for every patient at DCH upon admission, transfer or as dictated by changes in clinical condition PEWS: Behavior/Cardiovascular/Respiratory

8. Background RRT was instituted at DCH in January 2008 Analysis of 2008 RRT data revealed that Direct admits from referring hospitals and from primary pediatrician’s offices were associated with a very high occurrence of Rapid Response (RR) calls within the 1 st hour of admission The Quick Assessment (QA) unit was instituted in our ER on July 13 th, 2009 to improve triage and to match optimal resource allocation to severity of illness on direct admissions and hence improve the overall quality of care.

9. Background Quick Assessment is a process used to evaluate a patient that presents to the triage area of the ED to determine the suitability of such patient for direct admission or the need for a full evaluation and treatment in the ED. Vital signs are obtained by the nursing staff and the patient is assessed by ED physician utilizing the quick assessment tool.

11. Hypothesis The institution of a QA unit at DCH would decrease the number of hyperacute RRT calls among direct admissions RRT at DCH will continue to positively impact the number of unexpected cardio-respiratory arrests outside the PICU environment and its attendant mortality Uncover areas of potential weakness through clinical trends in order to more readily identify patients at risk or vulnerable situations

12. Methods Study protocol approved by the DCH IRB Retrospective study involving a review of patients who required evaluation or treatment by the RRT and QA unit during their stay at DCH (01/01/2008 to 12/31/2009) Sample identified through the RRT case registry and Code Blue registry Clinical records obtained by the Health Information System and reviewed by at least two of the investigators

13. Methods Relevant clinical data extracted onto customized Excel spreadsheets Statistical analysis performed with the help of Dr. Jose Guardiola, Phd, Assistant Professor of Statistics, TAMUCC

14. Methods T-test: Normally distributed continuous variables Wilcoxon test Non-normally distributed continuous variables Chi-Square or Fisher Exact tests Categorical variables Z Test Comparison of proportions of an occurrence between two groups from independent observations

15. Patient distribution

17. Hyperacute RRs in 2009

19. PEWS of pts transferred to PICU after a RR call 2008 2009 0 1 2 3 4 5 6 7 8 9 10 PEWS NY PICU Transfer 0 1 2 3 4 5 6 7 8 PEWS NoYes PICU Transfer

20. Time to RR call from registration (in hours) 0 100 200 300 400 500 600 Time (hrs) After QABefore QA

23. Patient disposition post RR 2008 2009

24. Patient disposition post RR Before QA After QA

25. Code blue ratios (per 1000 admissions) and survival (percentage) trend

26. Some quality improving QA facts… 141 of all QAs were turned to ED evaluations 2 pts transferred to PICU instead of floor 2 pts taken to OR from ED directly after evaluation (Foreign body, Appendicitis) 1 - taken to radiology for reduction (intussusception) Total number of QA pts discharged from ED after evaluation – 5 Only 1 pt who came through QA had a RR call (the patient was from an outside hospital)

27. Conclusions Rapid Response Team at DCH continues to cause a significant reduction in episodes of cardio- respiratory arrest outside the PICU and increased patient survival Higher PEWS is still highly predictable of a subsequent need for Critical Care >50% patients continue to require critical care monitoring or treatment after a RRT call QA has effectively decreased the number of hyper acute RRs among direct admissions and also improved quality of patient care

28. Concern.. RRT utilization at DCH: 2008 – 0.56/100 occupied beds 2009 – 0.48/100 occupied beds National aggregate of RRT utilization 10/100 occupied beds

29. Future Considerations Considering… Continuing success of RRT at DCH Positive impact of QA on lowering the incidence of hyper acute RRs among direct admits Strategies to focus on.. Improve RRT utilization Closer monitoring of patients with higher PEWS score Ensure that all direct admits to go through QA- including Specialty MD Aim for lower PEWS (0-2) before admitting a pt from ED

30. At DCH We care…. We deliver…..